Procedure Coding System Research Articles

#5749 RATES OF SELECTED CARDIOVASCULAR AND NON-CARDIOVASCULAR EVENTS AMONG DIALYSIS PATIENTS WITH ANEMIA IN THE US MEDICARE POPULATION

Abstract Background and Aims The safety and efficacy of daprodustat in patients on dialysis were reported in ASCEND-D/ID trials [1,2]. Trials impose strict criteria for enrollment, making participants more narrowly selected than a broader population with disease who might benefit from treatment. We describe events, of which most were noted as safety events in ASCEND-D/ID trials, among general anemia “treatment eligible” (TE) patients on dialysis and patients similar to those in ASCEND-D/ID trials (“clinical trial-like” [CTL]) in the US. Method Using United States Renal Data System data, we conducted a retrospective cohort study of incident dialysis-dependent (IDD) patients from 2017–2019 and, separately, point prevalent dialysis-dependent (PDD) patients as of Jan 1 2018. Dialysis initiation date was the index date for IDD patients and Jan 1 2018 for PDD patients. We also required patients to have ≥6 months of continuous Medicare coverage before, and be aged ≥18 years on, index date. Patients with a history of kidney transplant or who had cancer during the year prior, and those who had a hospitalization for heart failure (HF), myocardial infarction (MI), or stroke in the 4 weeks before, the index date were excluded. For IDD patients, we required use of ESAs at the index date to support comparability to the PDD patients. The CTL cohort was a subset of the TE cohort, approximating eligibility in the ASCEND-D/ID trials. Patients were followed from index date to the earliest date of death, loss of Medicare coverage, kidney transplantation, or Dec 31 2019. We assessed cardiovascular (CV: all-cause death, HF, MI, stroke, thromboembolic events [TEEs], major cardiovascular events [MACE: death, MI, stroke] and MACE+HF) and non-CV (cancer, gastric erosions, ocular events, seizures, serious infections) events, derived from medical claims in the follow-up period using ICD-10 diagnosis, Healthcare Common Procedure Coding System, and Current Procedural Terminology codes. HF, MI, stroke, and serious infections were defined as inpatient events. First event rates for TE and CTL cohorts were calculated separately for IDD and PDD patients and expressed as number of events per 100 patient-years (PYs). Results Of IDD patients, 23,909 were in the TE and 6,962 in the CTL cohorts; corresponding numbers were 230,055 and 41,980 for PDD patients. Median follow-up was 12.6 and 13.8 months for the TE and CTL cohorts, respectively, in IDD patients; and 24 months for both TE and CTL cohorts in PDD patients. Mean ages were 70.3 and 71.0 years for the TE and CTL cohorts in IDD patients; and 63.3 and 64.1 years for the TE and CTL cohorts in PDD patients. For both IDD and PDD patients, the TE and CTL cohorts had similar demographics, but the TE cohorts had a slightly higher proportion of patients with comorbidities. First event rates are shown in the Table. TE cohorts had higher rates than CTL cohorts for most CV events (mortality, 17.3 vs 14.0 per 100 PYs in IDD and 16.8 vs 15.1 in PDD; MACE; 20.9 vs 17.5 in IDD and 20.3 vs 18.6 in PDD; MACE+HF, 25.6 vs 21.8 in IDD, 26.9 vs 25.1 in PDD). In IDD patients, HF was more common in the TE than the CTL cohort (7.1 vs 6.1) but was similar in PDD patients. MI, stroke, and TEEs (vascular access thrombosis [in hemodialysis patients only], deep venous thrombosis, and pulmonary embolism) had similar rates in the TE and CTL cohorts for both IDD and PDD patients. Serious infections were higher in the TE than the CTL cohort in both IDD and PDD patients. In PDD patients, gastric erosions were higher in the TE than the CTL cohort (40.0 vs 38.5) while ocular events and retinal hemorrhage were lower in the TE cohort. Conclusion Rates for most CV events were higher in TE cohorts, comprised of patients eligible for anemia treatment, compared with CTL cohorts mimicking trial participants. Rates of non-CV events did not show a consistent pattern. As expected, rates of VAT were higher in IDD than PDD patients. These findings further contextualize real-world event rates of interest in dialysis populations. Reported rates were crude (unadjusted) and should be interpreted with caution. Funding: GSK (study 217316).

#5810 SELECTED CARDIOVASCULAR (CV)/NON-CV EVENT RATES IN NON-DIALYSIS-DEPENDENT PATIENTS TREATED WITH ESAS IN US MEDICARE (2017–2019), BY CKD STAGE

Abstract Background and Aims The safety and efficacy of daprodustat in non-dialysis-dependent chronic kidney disease (CKD) patients have been reported in the ASCEND-ND trial [1]. However, CKD stage may affect both the need for anemia treatment as well as outcomes, including potential safety events for anemia treatment. This study describes cardiovascular (CV) and non-CV event rates by CKD stage among patients treated with erythropoietin-stimulating agents (ESAs) in the US Medicare population. Method Using Medicare data for all fee-for-service enrollees, we conducted a retrospective cohort study of patients who had diagnosis of CKD stages 3, 4, or 5 and a first use of ESA in 2017–2019. CKD stage was identified by ICD-10 codes; ESA use was derived using Healthcare Common Procedure Coding System (HCPCS) codes. The date of first ESA use was the index date and CKD stage was defined as the most recent diagnosis on or before index date. We further required patients to have at least 12 continuous months of Medicare Parts A and B coverage (also used as a washout period to identify new ESA users) prior to, and be aged ≥66 years on, the index date. Patients with a history of kidney transplant or who had cancer during the year prior, and those who had a hospitalization for heart failure (HF), myocardial infarction (MI), or stroke in the 4 weeks before, the index date were excluded. Patients were followed from index date to the earliest date of death, loss of Medicare coverage, kidney transplantation or dialysis, or December 31, 2019. Both CV (all-cause death, HF, MI, stroke, thromboembolic events [TEEs], MACE [death, stroke, MI], and MACE+HF) and non-CV (cancer, gastric erosions, ocular events, seizures, and serious infections) events were ascertained, derived from Medical claims using ICD-10 diagnosis, HCPCS, and Current Procedural Terminology codes in the follow-up period. HF, MI, stroke, and serious infection were defined as inpatient events. First event rates were calculated separately by CKD stage, expressed as number of events per 100 patient-years during the follow-up period. Results This study cohort included 50,206 patients; 22,332 had stage 3, 19,177 stage 4, and 8,697 stage 5 CKD at the index date. Median follow-up time was 11.5 months for patients with CKD stage 3, 8.9 months for patients with stage 4, and 3.7 months for patients with stage 5 CKD. Patients with higher (worse) CKD stages were slightly younger (mean ages for stages 3, 4, and 5 were 79.7, 79.1, and 76.8 years); with increasingly more males (42.9%, 45.1%, and 48.5%), increasingly more individuals of non-Hispanic Black race (14.2%, 15.7%, and 19.6%), with lower income (indicated by Medicare/Medicaid dual enrolment and Medicare Part D low-income subsidy), and lower proportion of comorbidities. Rates were higher for most CV events in patients with higher (worse) CKD stages (Table): death rates were 19.5, 22.1, and 28.1 per 100 patient-years for stages 3, 4, and 5, respectively; MI rates were 2.2, 2.9, and 3.2; HF rates were 12.5, 17.2, and 19.0; MACE rates were 22.0, 25.4, and 31.8; and MACE+HF rates were 31.0, 38.7 and 47.8, respectively. Rates of stroke were similar across CKD stages; but no pattern for TEE. For non-CV events, higher (worse) CKD stage had higher rates of first ocular events (17.2, 23.3, and 27.1) and seizures (2.3, 2.7, and 3.4), but lower rates of cancer (21.8, 14.2, and 10.2) and, within this, hematological malignancies (10.4, 4.11 and 2.3). Conclusion Medicare-covered ESA-treated patients with higher CKD stage had higher rates for most events assessed, while malignancy rates were lower. These findings may provide important context when assessing US event rates in non-dialysis-dependent CKD patients. Further investigation could clarify some of the differences between stages, such as rates of malignancy. Rates were reported as crude (unadjusted) and so should be interpreted with caution. Limiting the analysis to ESA-treated patients may have resulted in different event rates than would be expected to occur in the general CKD population. Funding: GSK (study 217316).

#5644 SELECTED CARDIOVASCULAR AND NON-CARDIOVASCULAR EVENTS IN INCIDENT AND PREVALENT DIALYSIS PATIENTS IN THE US MEDICARE POPULATION

Abstract Background and Aims The ASCEND-D/ID trial reported safety and efficacy of daprodustat in patients receiving dialysis [1,2]. Rates and types of clinical outcomes vary between incident and prevalent dialysis patients. This study assessed events, of which most were described as safety events in ASCEND-D/ID trial, among incident dialysis patients on erythropoiesis-stimulating agents (ESAs) and prevalent dialysis patients in the US Medicare population. Method This is a retrospective, observational cohort study using United States Renal Data System data. The study included incident dialysis-dependent (IDD) patients from 2017–2019 and, separately, prevalent dialysis-dependent (PDD) patients as of January 1, 2018. For IDD patients, the index date was the dialysis initiation date; for PDD patients, the index date was January 1, 2018. To establish the cohorts, we further required patients to have at least 6 continuous months of Medicare Parts A and B coverage prior to, and be aged ≥18 years on, the index date. For IDD patients, we also required ESA use on the index date to better support comparability to the PDD patients. Patients with a history of kidney transplant or who had cancer during the year prior to, or who had a hospitalization for heart failure (HF), myocardial infarction (MI), or a stroke in the 4 weeks before, the index date were excluded. Patients were followed from index date (for IDD patients, follow-up started from index date plus 60 days to ascertain dialysis modality stability) to the earliest date of death, loss of Medicare coverage, kidney transplantation, or December 31, 2019. Events assessed were cardiovascular (CV: all-cause death, HF, MI, stroke, thromboembolic events [TEE], major adverse CV events [MACE: composite of death, MI, stroke], and MACE+HF) and non-CV (cancer, gastric erosions, ocular events, seizures, serious infection) events, derived from medical claims in the follow-up period using ICD-10 diagnosis, Healthcare Common Procedure Coding System, and Current Procedural Terminology codes in the follow-up period. HF, MI, stroke, and serious infection events were defined as inpatient events. TEEs included vascular access thrombosis (VAT), deep venous thrombosis (DVT), and pulmonary embolism (PE). First event rates were calculated separately for IDD and PDD cohorts and expressed as number of events per 100 patient-years. Results The IDD cohort contained 23,909 patients; the PDD cohort, 230,055. Median follow-up time was 12.6 months for the IDD cohort and 24.0 months for PDD cohort. Mean ages of the IDD and PDD cohorts were 70.3 and 63.3 years, respectively. Compared with the PDD cohort, patients in the IDD cohort were more likely to be female (48.2% vs 43.7%), of non-Hispanic White race (61.6% vs 40.4%), less likely be of lower-income status (33.0% vs 47.4% for Medicare/Medicaid dual enrollment and 38.6% vs 57.0% for Part D low-income subsidy) and with higher proportion of comorbidities. First event rates are shown in the Table for the IDD and PDD cohorts. Compared with the PDD cohort, patients in the IDD cohort had higher rates of all-cause mortality (17.3 vs 16.8 per 100 patient-years), stroke (1.8 vs 1.4), VAT (109.4. vs 67.2, hemodialysis patients only), and MACE (20.9 vs 20.3); however, they had lower rates of MI (3.1 vs 3.5), HF (7.1 vs 8.9), DVT (3.2 vs 4.0), and MACE+HF (25.6 vs 26.9). For non-CV events, patients in the IDD cohort had lower event rates for nearly all events except malignancies. Conclusion ESA-treated IDD patients had higher event rates for some CV events but lower rates for most non-CV events compared with PDD patients. As expected, however, rates of VAT were higher in IDD patients than PDD patients. These background event rates in real-world populations with wide ESA use provide context when considering potential alternative treatments for anemia. Limitation of this descriptive study includes the reporting of crude (unadjusted) rates, and therefore should be interpreted with caution. Funding: GSK (study 217316).

Real-world analysis of healthcare resource utilization by patients with X-linked myotubular myopathy (XLMTM) in the United States

BackgroundX-linked myotubular myopathy (XLMTM) is a rare, life-threatening congenital myopathy with multisystem involvement, often requiring invasive ventilator support, gastrostomy tube feeding, and wheelchair use. Understanding healthcare resource utilization in patients with XLMTM is important for development of targeted therapies but data are limited.MethodsWe analyzed individual medical codes as governed by Healthcare Common Procedure Coding System, Current Procedural Terminology, and International Classification of Diseases, 10th Revision (ICD-10) for a defined cohort of XLMTM patients within a US medical claims database. Using third-party tokenization software, we defined a cohort of XLMTM patient tokens from a de-identified dataset in a research registry of diagnostically confirmed XLMTM patients and de-identified data from a genetic testing company. After approval of an ICD-10 diagnosis code for XLMTM (G71.220) in October 2020, we identified additional patients.ResultsA total of 192 males with a diagnosis of XLMTM were included: 80 patient tokens and 112 patients with the new ICD-10 code. From 2016 to 2020, the annual number of patients with claims increased from 120 to 154 and the average number of claims per patient per year increased from 93 to 134. Of 146 patients coded with hospitalization claims, 80 patients (55%) were first hospitalized between 0 and 4 years of age. Across all patients, 31% were hospitalized 1–2 times, 32% 3–9 times, and 14% ≥ 10 times. Patients received care from multiple specialty practices: pulmonology (53%), pediatrics (47%), neurology (34%), and critical care medicine (31%). The most common conditions and procedures related to XLMTM were respiratory events (82%), ventilation management (82%), feeding difficulties (81%), feeding support (72%), gastrostomy (69%), and tracheostomy (64%). Nearly all patients with respiratory events had chronic respiratory claims (96%). The most frequent diagnostic codes were those investigating hepatobiliary abnormalities.ConclusionsThis innovative medical claims analysis shows substantial healthcare resource use in XLMTM patients that increased over the last 5 years. Most patients required respiratory and feeding support and experienced multiple hospitalizations throughout childhood and beyond for those that survived. This pattern delineation will inform outcome assessments with the emergence of novel therapies and supportive care measures.

Intrathecal drug delivery systems for cancer pain control: Insights on current contemporary practices in the US.

6605 Background: About a third of cancer survivors report moderate to severe pain. Intrathecal drug delivery system (IDDS) is an implantable pain control option for treating intractable chronic pain not responsive to systemic opioid therapy. Studies on the current practices in the US around the utilization of IDDS for cancer pain are lacking. Methods: The Nationwide inpatient sample (NIS) dataset is funded by the Agency for healthcare research and quality (AHRQ) for multistate healthcare research & decision-making. Adult patients admitted to hospitals with a primary or secondary cancer diagnosis between 2016-19 were included. Patients undergoing IDDS implantation were identified using the validated International Classification of Diseases, 10th Revision, Procedure Coding System codes (00HU33Z Insertion of infusion device into spinal canal, percutaneous approach and 0JH80VZ Insertion of infusion pump into abdomen subcutaneous tissue and fascia, open). Baseline demographics, hospital characteristics, and type of cancer associated with IDDS implantation were evaluated in the study. Results: 22,895 patients underwent IDDS surgery amongst 7.06 million hospitalizations from 2016-19. The IDDS cohort consisted of patients in the 65-79 years age group (40.49%), female sex (50.42%), and Caucasian ethnicity (75.82%). Most IDDS surgeries were performed in large, urban teaching hospitals. Conclusions: Despite recommendations supporting IDDS use, a small minority received the treatment with significant racial & socioeconomic disparities in IDDS use. [Table: see text]

Assessing the marginal costs of radiation therapy and antiestrogen therapy for post-lumpectomy, early-stage breast cancer across Medicaid and Medicare plans.

529 Background: With recent Level I evidence (FAST FORWARD) supporting radiation therapy (RT) duration as short as one week and Level I evidence (CALGB9343) supporting RT omission in favor of antiestrogen endocrine therapy (ET) alone in select patients, the necessity of both RT and ET, adjuvantly, in early-stage breast cancer (BC) has been questioned. Evidence providing granular details on the role of insurance in the aggregate cost of RT and ET is lacking. This project disaggregates costs by insurance plan to increase transparency of out-of-pocket (OOP) cost estimates. Methods: National Comprehensive Cancer Network guidelines were utilized to determine the proper treatments, with FAST FORWARD radiation dose/fractionation (26 Gy in 5 fractions) representing RT. Treatments were identified using Current Procedural Terminology and Healthcare Common Procedure Coding System codes. OOP costs, deductibles, and copay/coinsurance were calculated for Medicaid, Original Medicare, Medigap Plan G, and Medicare Part D Rx. The medicare.gov, medicaid.oh.gov, aarpmedicareplans.com, and cms.gov were used to determine pricing. Price estimates reflect actual costs per insurance plan rather than costs estimated from claims data. All procedures were considered to be performed in an Ohio hospital setting, insurance coverages were based on the zip code 44106, and total expenses were based on all treatments plus a 5-year follow-up (not adjusted for inflation). Results: Treatment charges for ET include medical oncology initial consultation, biannual medical oncology follow-up, baseline bone density study, and Anastrozole cost (5-years). Treatment charges for RT include initial consultation, treatment planning, dosimetry calculations, treatment device, simulation and verification, RT delivery, on-treatment visits, and medical physics consultation. Original Medicare beneficiaries face an OOP cost of 20% for Medicare Part B claims with no cost cap for approved procedures after the deductible. Medications are covered under Medicare Part D with copays. This results in a marginal OOP treatment charge (after 5-year follow-up) of $767.54 for ET alone and $1,416.78 for ET + RT. Medigap Plan G beneficiaries face a marginal OOP charge of $1,225 for both ET alone and ET + RT, assuming the $226 Medicare Plan B deductible is met by the cost of lumpectomy during the year of RT. For Medicaid beneficiaries (assuming all treatments are approved by Medicaid), all expenses are covered without limit, resulting in no OOP expense for either treatment plan. Conclusions: Discussions of adding RT to ET for post-lumpectomy early-stage BC often involves considerations of treatment costs. This model (based on actual cost estimates per insurance plan rather than claims data) can help to enhance cost transparency by comparing expenses between Medicare and Medicaid plans.

Evaluating access to brentuximab in elderly patients with Hodgkin lymphoma.

e18663 Background: Despite the high survival associated with Hodgkin lymphoma (HL), established disparities exist both in survival for Black and Hispanic patients and their access to consolidative treatments like radiotherapy as demonstrated using large, population-based databases. Elderly patients with HL face inferior survival compared to younger patients. Brentuximab is an approved second line therapy for those patients with refractory/relapsed HL. We examined whether there were inequities in receipt of treatment among those diagnosed with HL in a contemporary cohort receiving frontline doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD), allowing for evaluation of targeted therapy. Methods: Data from Surveillance Epidemiology and End-Results (SEER) linked to Medicare claims were used to identify individuals diagnosed with HL from 2008 to 2017 who received frontline treatment with ABVD using applicable Healthcare Common Procedure Coding System codes. We examined differences in associations with receipt of brentuximab following ABVD within two years of diagnosis. Descriptive statistics were used to characterize the sample. We ran univariable and multivariable logistic regression models (producing adjusted odds ratios, aOR and 95% confidence intervals, CI) predicting treatment with brentuximab. Multivariable models were adjusted for age at diagnosis, sex, race/ethnicity, stage, insurance at diagnosis, and geographic location. Results: A total of 2,651 people diagnosed with HL were identified, 2,007 (76%) of which survived two years and 1,475 (56%) were still alive at last follow-up in 2019. Mean age at diagnosis was 69 years (SD: 12.4), most were men (N = 1,457, 55%), non-Hispanic White (N = 2,050, 77%), Hispanic (N = 291, 11%), or non-Hispanic Black (N = 220, 8%), diagnosed with stage I or II disease (N = 1,591, 60%), and received radiotherapy (N = 663, 23%) or brentuximab (N = 181, 7%) within two years of diagnosis. On univariable analysis, race and ethnicity did not have a statistically significant association with receipt of brentuximab as adjuvant treatment within two years of diagnosis. On multivariable analysis, individuals without insurance at diagnosis (aOR 1.54; 95% CI 1.02, 2.30) or those diagnosed with stage III or IV disease (aOR 2.04; 95% CI 1.04, 2.98) were more likely to receive brentuximab as adjuvant treatment within two years of diagnosis, after adjusting for the variables described above. Conclusions: Although we cannot definitively say that receipt of brentuximab within two years of diagnosis following ABVD is due to relapse, we posit that this can be used as a proxy for relapse. Our analysis did not demonstrate that race and ethnicity rose to traditional levels of statistical significance regarding associations with decreased odds of receiving brentuximab. In multivariable analysis, patients without insurance or diagnosed with stage III or IV disease were more likely to receive brentuximab.

Inconsistency and Ambiguity Within the International Classification of Disease 10 Procedure Coding System for Hip Fractures

BackgroundThe International Statistical Classification of Diseases (ICD), 10th Revision Procedure Coding System (PCS) was created to increase the granularity of procedural coding. These codes are entered by hospital coders from information derived from the medical record. Concern exists that this increase in complexity could lead to inaccurate data. MethodsMedical records and ICD-10-PCS codes were reviewed for operatively treated geriatric hip fractures from January 2016 through February 2019 at a tertiary referral medical center. Definitions for each of the 7-unit figures from the 2022 American Medical Association’s ICD-10-PCS official codebook were compared to the medical, operative, and implant records. ResultsThere were 56% (135 of 241) of PCS codes that had ambiguous, partially incorrect, or frankly incorrect figures within the code. One or more inaccurate figures were noted in 72% (72 of 100) of fractures treated with arthroplasty compared to 44.7% (63 of 141) treated with fixation (P < .01). There was at least 1 frankly incorrect figure contained in 9.5% (23 of 241) of codes. Approach was coded ambiguously for 24.8% (29 of 117) of pertrochanteric fractures. Device/implant codes were partially incorrect in 34.9% (84 of 241) of all hip fracture PCS codes. Hemi and total hip arthroplasties were partially incorrect in 78.4% (58 of 74) and 30.8% (8/26) of device/implant codes, respectively. Significantly more femoral neck (69.4%, 86 of 124) than pertrochanteric fractures (41.9%, 49 of 117) had 1 or more incorrect or partially correct figures (P < .01). ConclusionDespite the increased granularity of ICD-10-PCS codes, the application of this system is inconsistent and often incorrect when applied to hip fracture treatments. The definitions in the PCS system are difficult to be utilized by coders and do not reflect the operation performed.

Benchmarking the Radiation Oncology Alternative Payment Model: Changes in Medicare Reimbursement for 16 Common Radiation Therapy Treatment Courses

Radiation oncology (RO) has seen declines in Medicare reimbursement (MCR) in the past decade under the current fee-for-service model. Although studies have explored decline in reimbursement at a per-code level, to our knowledge there are no recent studies analyzing changes in MCR over time for common RO treatment courses. By analyzing changes in MCR for common treatment courses, our study had 3 objectives: (1) to provide practitioners and policymakers with estimates of recent reimbursement changes for common treatment courses; (2) to provide an estimate of how reimbursement will change in the future under the current fee-for-service model if current trends continue; and (3) to provide a baseline for treatment episodes in the event that the episode-based Radiation Oncology Alternative Payment Model is eventually implemented. Specifically, we quantified inflation- and utilization-adjusted changes in reimbursement for 16 common radiation therapy (RT) treatment courses from 2010 to 2020. Centers for Medicare & Medicaid Services Physician/Supplier Procedure Summary databases were used to obtain reimbursement for all RO procedures in 2010, 2015, and 2020 for free-standing facilities. Inflation-adjusted average reimbursement (AR) per billing instance was calculated for each Healthcare Common Procedure Coding System code using 2020 dollars. For each year, the billing frequency of each code was multiplied by the AR per code. Results were summed per RT course per year, and AR for RT courses were compared. Sixteen common RO courses for head and neck, breast, prostate, lung, and palliative RT were analyzed. AR decreased for all 16 courses from 2010 to 2020. From 2015 to 2020, the only course that increased in AR was palliative 2-dimensional 10-fraction 30 Gy, which increased by 0.4%. Courses using intensity modulated RT saw the largest AR decline from 2010 to 2020, ranging from 38% to 39%. We report significant declines in reimbursement from 2010 to 2020 for common RO courses, with the largest declines for intensity modulated RT. Policymakers should consider the significant cuts to reimbursement that have already occurred when considering future reimbursement adjustment under the current fee-for-service model or when considering mandatory adoption of a new payment system with further cuts and the negative effect of such cuts on quality and access to care.

Surgical markup in lung cancer resection, 2015-2020

ObjectiveThe objective of this study was to assess procedure markup (charge-to-cost ratio) across lung resection procedures and examine variability by geographic region. MethodsProvider-level data for common lung resection operations was obtained from the 2015 to 2020 Medicare Provider Utilization and Payment Data datasets using Healthcare Common Procedure Coding System codes. Procedures studied included wedge resection; video-assisted thoracoscopic surgery; and open lobectomy, segmentectomy, and mediastinal and regional lymphadenectomy. Procedure markup ratio and coefficient of variation (CoV) was assessed and compared across procedure, region, and provider. The CoV, a measure of dispersion defined as the ratio of the SD to the mean, was likewise compared across procedure and region. ResultsMedian markup ratio across all procedures was 3.56 (interquartile range, 2.87-4.59) with right skew (mean, 4.13). Median markup ratio was 3.59 for lymphadenectomy (CoV, 0.51), 3.13 for open lobectomy (CoV, 0.45), 3.55 for video-assisted thoracoscopic surgery lobectomy (CoV, 0.59), 3.77 for segmentectomy (CoV, 0.74), and 3.80 for wedge resection (CoV, 0.67). Increased beneficiaries, services, and Healthcare Common Procedure Coding System score (total) were associated with a decreased markup ratio (P < .0001). Markup ratio was highest in the Northeast at 4.14 (interquartile range, 3.09-5.56) and lowest in the South (Markup ratio 3.26; interquartile range, 2.68-4.02). ConclusionsWe observe geographic variation in surgical billing for thoracic surgery.

Longer Milestone-Free Time in Patients With Amyotrophic Lateral Sclerosis Treated With IV Edaravone vs Not Treated With IV Edaravone: Results From a US Administrative Claims Analysis (S14.007)

<h3>Objective:</h3> To estimate time-to-progression milestones in IV edaravone–treated vs non–IV edaravone-treated patients with ALS in a real-world setting. <h3>Background:</h3> Intravenous (IV) edaravone was US Food and Drug Administration-approved in May 2017 based on a slowing of functional decline in patients with amyotrophic lateral sclerosis (ALS). Information on real-world outcomes in patients with ALS treated with IV edaravone is limited. <h3>Design/Methods:</h3> This retrospective observational analysis included patients with ALS who were continuously enrolled in Optum’s de-identified Clinformatics® Data Mart database between August 8, 2017, and September 30, 2021. Propensity score matching (1:1) identified IV edaravone–treated patients (cases) and non–IV edaravone-treated patients (controls) matched for covariates: age, race, geographic region, gender, pre-index disease duration (period between the first claim for ALS diagnosis and the first claim for IV edaravone [cases] or August 2017 [controls]), insurance, cardiovascular disease history, riluzole prescription, gastrostomy tube placement, artificial nutrition, noninvasive ventilation, and all-cause hospitalization. Milestones were defined according to the Healthcare Common Procedure Coding System and included the use of canes/walkers/wheelchairs (M1); artificial nutrition (M2); noninvasive ventilation (M3); invasive ventilation/speech-generating devices (M4); and hospice (M5). Difference between cases and controls in cause-specific restricted mean time lost (RMTL) was estimated to examine IV edaravone benefit. <h3>Results:</h3> Cases (n=360) were matched to controls (n=360); mean age in years (SD) was 62.9 (10.2) and 62.8 (10.2) in cases and controls, respectively. In the post-index period, differences in RMTL (95% CI) in months indicate longer milestone-free time in cases than controls: 2.50 (0.93–4.07), 4.30 (2.88–5.72), 2.92 (1.56–4.28), 4.12 (3.00–5.23), and 2.33 (1.31–3.34) for M1, M2, M3, M4, and M5, respectively. <h3>Conclusions:</h3> This analysis describes the time to milestones in patients with ALS treated with IV edaravone in a real-world setting. This information may be useful to payers and clinicians in evaluating use of IV edaravone. <b>Disclosure:</b> Malgorzata Ciepielewska has received personal compensation for serving as an employee of Mitsubishi Tanable Pharma America . Jeffrey Zhang has received personal compensation for serving as an employee of Princeton Pharmatech. Jeffrey Zhang has received stock or an ownership interest from CalciMedica. Ying Liu has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for MPTA. Dr. Hagan has received personal compensation for serving as an employee of Mitsubishi Tanabe Pharma America.

Sickle Cell Anemia Associated With Increased In-Hospital Mortality in Post-Cardiac Arrest Patients.

Introduction Sickle cell anemia (SCA) is a hemoglobinopathy that arises from a point mutation in the beta-globin gene, which causes the polymerization of deoxygenated hemoglobin that leads to a wide variety of clinical complications. Deaths in patients with SCA most commonly arise from renal, cardiovascular disease, infections, and stroke. In-hospital cardiac arrest has been found to be more common in older patients and those on ventilatory life support, among others. This study aims to provide more insight into how SCA affects the risk of in-hospital mortality in post-cardiac arrest patients. Methods The National Inpatient Survey database years 2016 to 2019 was utilized. The International Classification of Diseases, Tenth Revision, ProcedureCoding System (ICD-10 PCS) codes for cardiopulmonary resuscitation were used to identify in-hospital cardiac arrest (IHCA) patients. ICD-10 Clinical Modification (CM) codes were used to identify SCA and other medical comorbidities. Categorical data was compared using Person's chi-square test, and continuous variables were compared using the independent samples t-test.Multinomial logistic regression was used to study the effects of SCA on post-arrest in-hospital mortality controlling for age, Charlson comorbidity score, and demographic variables. Binomial logistic regression models for dichotomous variables were utilized in the subgroup and secondary outcomes analysis. Results In patients with IHCA, patients who had SCA were found to have a significantly increased risk of in-hospital mortality adjusted for baseline characteristics and Charlson comorbidity score (OR: 1.16, 95% CI: 1.02-1.32, p=0.0025). Patient characteristics most strongly associated with an increased risk of in-hospital mortality in this cohort were found to be Black race (OR: 1.92, 95% CI: 1.87-1.97, p<0.001) and self-payer status (OR: 2.14, 95% CI: 2.06-2.22, p<0.001). Subgroup analysis revealed only patients with sickle cell disease had a statistically significant increased risk of in-hospital mortality in this cohort (OR: 4.41, 95% CI: 3.5-5.55, p<0.001), and patients with sickle cell trait did not. Conclusion In patients with IHCA, SCA is associated with an increased risk of in-hospital mortality. This risk was confined to patients with sickle cell disease and not patients with sickle cell trait.

Safety of endoscopic pancreatic necrosectomy compared with percutaneous and surgical necrosectomy: a nationwide inpatient study.

Background and study aims Pancreatic necrosis is an independent predictor of morbidity and mortality among patients with acute pancreatitis. We compared the safety and outcomes of three techniques including endoscopic necrosectomy, fluoroscopy-guided percutaneous necrosectomy by an interventional radiologist, and surgical necrosectomy. Patients and methods Using the Nationwide Readmissions Database, we identified hospitalized patients who underwent pancreatic necrosectomy from 2016 to 2019. They were identified using the International Classification of Diseases, 10th Revision, Procedure Coding System. Results: Of the 2,281 patients meeting the selection criteria, the method of pancreatic necrosectomy was as follows: endoscopy (n = 672), percutaneous (n = 1,338), and surgery (n = 271). Compared to surgery, the rate of mortality was lowest for endoscopy (hazard ratio (HR) 0.27; 95 % CI 0.08-0.90; P = 0.033) followed by percutaneous (HR 0.44; 95 % CI, 0.20-0.98; P = 0.045). Endoscopy was associated with less post-procedure bleeding compared to percutaneous and surgical necrosectomy ( P < 0.001), as well as lower rates of post-procedure renal failure ( P < 0.001) and respiratory failure ( P = 0.002). Endoscopy was associated with average shorter lengths of stay and total hospital costs when compared with percutaneous and surgical approaches, respectively (20.1 vs 25.8 vs 38.3 days; P < 0.001) and ($ 57K vs $ 76K vs $ 123K; P < 0.001). Conclusions Endoscopic necrosectomy is associated with significantly lower risk of inpatient mortality, adverse events, length of stay, and cost when compared to percutaneous and surgical approaches.

Prolonged Services: CPT® Guidelines and Medicare/Medicaid Policy

This article addresses the following topics: Current Procedural Terminology (CPT) codes for prolonged evaluation and management (E/M) service codes are reported based on the occurrence or absence of a face-to-face visit on the same date in addition to time requirements. The Centers for Medicare &amp; Medicaid Services (CMS) created Healthcare Common Procedure Coding System (HCPCS) codes with guidelines that vary significantly from the CPT guidelines. CMS does not always limit the time attributed to prolonged service to time on the date of the encounter.

MP48-07 NATIONAL TRENDS OF COMMON FEMALE PELVIC MEDICINE AND RECONSTRUCTIVE SURGERY PROCEDURES: 2016-2019

You have accessJournal of UrologyCME1 Apr 2023MP48-07 NATIONAL TRENDS OF COMMON FEMALE PELVIC MEDICINE AND RECONSTRUCTIVE SURGERY PROCEDURES: 2016-2019 Connie Wang, Daniel Schoenfeld, Joseph Marte, and Gregory Joice Connie WangConnie Wang More articles by this author , Daniel SchoenfeldDaniel Schoenfeld More articles by this author , Joseph MarteJoseph Marte More articles by this author , and Gregory JoiceGregory Joice More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003294.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To evaluate national trends in settings and charges of common female pelvic medicine and reconstructive surgery (FPMRS) procedures. METHODS: Common FPMRS procedures were identified by Current Procedural Terminology and International Classification of Diseases (10th Revision) Procedure Coding System codes and classified into 3 categories: 1) stress urinary incontinence procedures (SUI-p) 2) pelvic organ prolapse procedures (POP-p) and 3) overactive bladder procedures (OAB-p). Data from inpatient (IP) and outpatient (OP) encounters for included procedures between 2016-2019 were extracted from the Nationwide Inpatient Sample and Nationwide Ambulatory Surgery Sample from the Healthcare Cost and Utilization Project. Stratified cluster sampling was used to create weighted, national estimates. Student t-tests and multivariable linear regression was performed to compare procedural factors. RESULTS: A total of 893,450 weighted procedures were analyzed, of which 9.3% were performed IP and 90.7% were performed OP. Over the study period, there was a 4.3% increase in total number of procedures, and the proportion performed OP increased from 88.1% to 92.5%. Between 2016-2019, there was a 10.6% and 10.5% increase in SUI-p and POP-p performed OP, respectively. Over the study period, proportion of SUI-p performed OP increased from 96.4% to 99.7%, and proportion of POP-p performed OP increased from 76.5% to 82.8%. 99.9% of OAB-p were performed OP. Charges for SUI-p performed IP were $16,705 higher than those performed OP (p=0.007) and charges for POP-p performed IP were $21,864 higher than those performed OP (p<0.0001). Predictors of SUI-p and POP-p being performed OP included private insurance, fewer co-morbidities, and receiving care at a rural facility or at a center in the Midwest or South. Additionally, SUI-p were more likely to be performed OP for patients < 52 years of age. POP-p were more likely to be performed IP than SUI-p (OR 20.8; 95% CI 20.2 - 21.5), while OAB-p were less likely to be performed IP than SUI-p (OR 0.01; 95% CI 0.01 – 0.02). CONCLUSIONS: An increasing majority of SUI and OAB procedures performed nationwide are performed in OP settings. These procedures performed OP carry less charge than those performed IP and are more likely for younger, healthier patients with private insurance. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e657 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Connie Wang More articles by this author Daniel Schoenfeld More articles by this author Joseph Marte More articles by this author Gregory Joice More articles by this author Expand All Advertisement PDF downloadLoading ...

Surgical subspecialization is associated with higher rate of rib fracture stabilization: a retrospective database analysis

BackgroundSurgical stabilization of rib fractures (SSRF) is performed on only a small subset of patients who meet guideline-recommended indications for surgery. Although previous studies show that provider specialization was associated...

Using Pointwise Mutual Information for Breast Cancer Health Disparities Research With SEER-Medicare Claims.

Identification of procedures using International Classification of Diseases or Healthcare Common Procedure Coding System codes is challenging when conducting medical claims research. We demonstrate how Pointwise Mutual Information can be used to find associated codes. We apply the method to an investigation of racial differences in breast cancer outcomes. We used Surveillance Epidemiology and End Results (SEER) data linked to Medicare claims. We identified treatment using two methods. First, we used previously published definitions. Second, we augmented definitions using codes empirically identified by the Pointwise Mutual Information statistic. Similar to previous findings, we found that presentation differences between Black and White women closed much of the estimated survival curve gap. However, we found that survival disparities were completely eliminated with the augmented treatment definitions. We were able to control for a wider range of treatment patterns that might affect survival differences between Black and White women with breast cancer.

Mark-Up Trends in Contemporary Medicare Primary and Revision Total Joint Arthroplasty

BackgroundUnderstanding mark-up ratios (MRs), the ratio between a healthcare institution’s submitted charge and the Medicare payment received, for high-volume orthopaedic procedures is imperative to inform policy about price transparency and reducing surprise billing. This analysis examined the MRs for primary and revision total hip and knee arthroplasty (THA and TKA) services to Medicare beneficiaries between 2013 and 2019 across healthcare settings and geographic regions. MethodsA large dataset was queried for all THA and TKA procedures performed by orthopaedic surgeons between 2013 and 2019, using Healthcare Common Procedure Coding System (HCPCS) codes for the most frequently used services. Yearly MRs, service counts, average submitted charges, average allowed payments, and average Medicare payments were analyzed. Trends in MRs were assessed. We evaluated 9 THA HCPCS codes, averaging 159,297 procedures a year provided by a mean of 5,330 surgeons. We evaluated 6 TKA HCPCS codes, averaging 290,244 procedures a year provided by a mean of 7,308 surgeons. ResultsFor knee arthroplasty procedures, a decrease was noted for HCPCS code 27438 (patellar arthroplasty with prosthesis) over the study period (8.30 to 6.62; P = .016) and HCPCS code 27447 (TKA) had the highest median (interquartile range [IQR]) MR (4.73 [3.64 to 6.30]). For revision knee procedures, the highest median (IQR) MR was for HCPCS code 27488 (removal of knee prosthesis; 6.12 [3.83-8.22]). While no trends were noted for both primary and revision hip arthroplasty, median (IQR) MRs in 2019 for primary hip procedures ranged from 3.83 (hemiarthroplasty) to 5.06 (conversion of previous hip surgery to THA) and HCPCS code 27130 (total hip arthroplasty) had a median (IQR) MR of 4.66 (3.58-6.44). For revision hip procedures, MRs ranged from 3.79 (open treatment of femoral fracture or prosthetic arthroplasty) to 6.10 (revision of THA femoral component). Wisconsin had the highest median MR by state (>9) for primary knee, revision knee, and primary hip procedures. ConclusionThe MRs for primary and revision THA and TKA procedures were strikingly high, as compared to nonorthopaedic procedures. These findings represent high levels of excess charges billed, which may pose serious financial burdens to patients and must be taken into consideration in future policy discussions to avoid price inflation.

The role of restrictive scope-of-practice regulations on the delivery of nurse practitioner-delivered home-based primary care.

Nurse practitioners (NPs) are the largest group of providers delivering home-based primary care (HBPC) in the U.S. We examined the association of scope-of-practice regulations and NP-HBPC rates. Using the Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Public Use File for 2019, we conducted a state-level analysis to examine the impact of scope-of-practice regulations on the utilization of NP-HBPC. Healthcare Common Procedure Coding System codes were used to identify the HBPC visits in private residences (99341-99,345, 99,347-99,350) and domiciliary settings (99324-99,328, 99,334-99,337). We used linear regression to compare NP-HBPC utilization rates between states of either restricted or reduced scope-of-practice laws to states with full scope-of-practice, adjusting for a number of NP-HBPC providers, state ranking of total assisted living, the proportion of fee-for-service (FFS) Medicare beneficiaries and neighborhood-level socio-economic status and race and ethnicity. Nearly half of NPs providing HBPC (46%; n=7151) were in states with a restricted scope of practice regulations. Compared to states with full scope-of-practice, states with restricted or reduced scope-of-practice had higher adjusted rates of NP-HBPC per 1000 FFS Medicare beneficiaries. The average level of the utilization rate of NP-HBPC was 89.9, 63, and 49.1 visits, per 1000 FFS Medicare beneficiaries in states with restricted, reduced, and full- scope-of-practice laws, respectively. The rate of NP-HBPC visits was higher in states with restricted (Beta coefficient=0.92; 95%CI 0.13-1.72; p=0.023) and reduced scope-of-practice laws (Beta coefficient=0.91; 95%CI 0.03-1.79; p=0.043) compared to states with full scope-of-practice laws. Restricted state NP scope-of-practice regulations were associated with higher rates of FFS Medicare NP-HBPC care delivery compared with full or reduced scope-of-practice. Understanding underlying mechanisms of how scope-of-practice affects NP-HBPC delivery could help to develop scope-of-practice regulations that improve access to HBPC for the underserved homebound population.

Postoperative Antibiotics Confer No Protective Association After Fat Grafting for Breast Reconstruction.

Autologous fat grafting after breast reconstruction is a commonly used technique to address asymmetry and irregularities in breast contour. While many studies have attempted to optimize patient outcomes after fat grafting, a key postoperative protocol that lacks consensus is the optimal use of perioperative and postoperative antibiotics. Reports suggest that complication rates for fat grafting are low relative to rates after reconstruction and have been shown to not be correlated to antibiotic protocol. Studies have additionally demonstrated that the use of prolonged prophylactic antibiotics do not lower the complication rates, stressing the need for a more conservative, standardized antibiotic protocol. This study aims to identify the optimal use of perioperative and postoperative antibiotics that optimizes patient outcomes. Patients in the Optum Clinformatics Data Mart who underwent all billable forms of breast reconstruction followed by fat grafting were identified via Current Procedural Terminology codes. Patients meeting inclusion criteria had an index reconstructive procedure at least 90 days before fat grafting. Data concerning these patient's demographics, comorbidities, breast reconstructions, perioperative and postoperative antibiotics, and outcomes were collected via querying relevant reports of Current Procedural Terminology; International Classification of Diseases, Ninth Revision; International Classification of Diseases, Tenth Revision; National Drug Code Directory, and Healthcare Common Procedure Coding System codes. Antibiotics were classified by type and temporal delivery: perioperatively or postoperatively. If a patient received postoperative antibiotics, the duration of antibiotic exposure was recorded. Outcomes analysis was limited to the 90-day postoperative period. Multivariable logistic regression was performed to ascertain the effects of age, coexisting conditions, reconstruction type (autologous or implant-based), perioperative antibiotic class, postoperative antibiotic class, and postoperative antibiotic duration on the likelihood of any common postoperative complication occurring. All statistical assumptions made by logistic regression were met successfully. Odds ratios and corresponding 95% confidence intervals were calculated. From more than 86 million longitudinal patient records between March 2004 and June 2019, our study population included 7456 unique records of reconstruction-fat grafting pairs, with 4661 of those pairs receiving some form of prophylactic antibiotics. Age, prior radiation, and perioperative antibiotic administration were consistent independent predictors of increased all-cause complication likelihood. However, administration of perioperative antibiotics approached a statistically significant protective association against infection likelihood. No postoperative antibiotics of any duration or class conferred a protective association against infections or all-cause complications. This study provides national, claims-level support for antibiotic stewardship during and after fat grafting procedures. Postoperative antibiotics did not confer a protective benefit association against infection or all-cause complication likelihood, while administering perioperative antibiotics conferred a statistically significant increase in the likelihood that a patient experienced postoperative complication. However, perioperative antibiotics approach a significant protective association against postoperative infection likelihood, in line with current guidelines for infection prevention. These findings may encourage the adoption of more conservative postoperative prescription practices for clinicians who perform breast reconstruction, followed by fat grafting, reducing the nonindicated use of antibiotics.